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Deep venous thrombosis, pulmonary embolus, venous thromboembolism case

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Brief complaint:

MJ was a 63 year old woman who had a fatal pulmonary embolus after abdominoplasty. 

 

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Case summary:

MJ was a 63 year old woman who presented to Dr. SA with a chief complaint of excess abdominal skin and fat.  She desired abdominoplasty to improve her abdominal contour.  Past medical history was notable for a personal history of deep venous thrombosis (DVT) during a prior pregnancy.

The patient had never had genetic hypercoagulability testing. Past surgical history was notable for a non-cancerous arm mass removed under general anesthesia three weeks prior to her abdominoplasty. She had a body mass index of 32.0kg/m2. A standard abdominoplasty including rectus plication was performed under general anesthesia. Upper and lower lid blepharoplasty were performed during the same procedure, which lasted 245 minutes. Sequential compression devices were in place during the operation. She was admitted overnight but had poor pain control. She was discharged on post-operative day two to home. No chemical prophylaxis, such as unfractionated heparin or low molecular weight heparin, was provided. The patient was found dead at home on post-operative day five. An autopsy confirmed the cause of death as a saddle pulmonary embolus (PE). Standard of care and literature review: I have reviewed medical documentation including Dr. SA’s office note, the operative report, and the inpatient notes. There were no post-operative clinic notes as the patient died prior to her followup visit. I have reviewed the patient’s inpatient medical administration record and her operative charge sheets. There was no imaging available for review. Dr. SA’s initial consultation note included documentation of multiple risk factors for DVT/PE. Dr. SA did not perform an individualized venous thromboembolism (VTE) risk stratification using a Caprini score or similar, as recommended by the 2012 American Society of Plastic Surgeons VTE Task Force Report and the 2016 American Association of Plastic Surgeons VTE consensus panel. Had Dr. SA done so, a Caprini score of 9 (2 points for age 63, 3 points for personal history of DVT, 2 points for OR time>45 minutes, and 1 point each for BMI>25 and operative procedure within 30 days) would have been calculated. Dr. SA did not consider referral to hematology to evaluate for genetic hypercoagulability, and thus did not fully evaluate this patient’s propensity to clot. Dr. SA documented several modifiable VTE risk factors that were present, including the patient’s elevated BMI and recent operative procedure. Although the abdominoplasty was completely elective, Dr. SA did not delay the patient’s elective operation for hypercoagulability workup or to modify existing risk factors. Dr. SA’s clinic notes do not discuss the patient’s Caprini score of 9, which correlates to an 8.5% risk of post-operative VTE. Dr. SA’s clinic notes do not indicate that the patient was informed of her high risk for peri-operative VTE, or of risk modification/prevention strategies (see below). Dr. SA’s clinic notes do not indicate that the patient was informed that choosing not to have an operation was the only way to reduce her VTE risk to zero. The operation was performed under a general anesthesia. Dr. SA did not consider using a non-general anesthetic technique to reduce VTE risk, as has been recommended based on meta-analysis data in the 2016 American Association of Plastic Surgeons VTE consensus statement. Combination procedures (in this case, eyelid surgery and abdominal contouring) are a recognized risk factor for VTE, and Dr. SA did not consider performing the procedures separately to decrease VTE risk. Abdominal wall plication is known to increase intraabdominal pressure and promote lower extremity venous stasis. Dr. SA does not note whether the plication was truly necessary, or whether it was performed as a “matter of course”. Dr. SA did provide mechanical prophylaxis (sequential compression devices) during the operation. Data from the multicenter VTEPS study correlates Caprini score of 9 with an 8.5% risk for VTE at 60 days. Chemical prophylaxis would have reduced that risk by over 50%, to approximately 4.1%. Dr. SA did not provide chemical prophylaxis, nor was there any indication that Dr. SA considered providing chemical prophylaxis, to MJ during her inpatient hospitalization. The 2012 American Society of Plastic Surgeons VTE Task Force Report recommends that surgeons of high risk patients (including those having abdominoplasty) consider risk reduction strategies like limiting operating room time and provision of chemical prophylaxis for patients with high Caprini scores. The 2016 American Association of Plastic Surgeons VTE consensus panel explicitly recommend that surgeons consider chemical prophylaxis for patients with Caprini scores >8. If Dr. SA had provided chemical prophylaxis to MJ during her inpatient stay, her VTE risk would have been decreased by 50%. If Dr. SA had fully considered and informed MJ of her VTE risk in the pre-operative setting, her VTE risk could have been eliminated—she may have chosen not to have this completely elective operative procedure. Qualifications I am a fellowship-trained microvascular surgeon with an active, University-based plastic and reconstructive surgery practice. I am board certified by the American Board of Plastic Surgery. For the past ten years, my research efforts have examined peri-operative deep venous thrombosis (DVT) and pulmonary embolus (PE), collectively known as venous thromboembolism (VTE), in surgical patients. I have published 65 manuscripts in peer reviewed journals, the majority of which examine VTE risk stratification and prevention. My research efforts are active and examine VTE risk stratification and prevention amongst post-operative patients. My research currently receives funding from national societies and the federal government. I am well versed in current literature on DVT/PE risk stratification in all types of surgical patients, and have published and presented extensively in these areas. I have authored (either individually or as part of a panel) summary documents and consensus guidelines that define the current data-driven standard for VTE risk stratification and prevention amongst plastic and reconstructive surgery patients.
 
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